REPUBLIC OF THE PHILIPPINES}

______________............................} S.S.

AFFIDAVIT OF LOSS
I, OWEN B. FERNANDEZ, of legal age, married, Filipino, residing in and with postal
address at ________________ after having been duly sworn to according to law,
hereby depose and state:
1. That _______________ issued to me a Savings Account Passbook with
Account No. 12-4535-001 and my said Savings Account has an amount of FIFTEEN
THOUSAND ONE HUNDRED PESOS (P15,150.00) presently deposited therein;
2. That on _____________ at around 9 oclock in the morning when I was at the
_________ Public Market, my said Savings Account Passbook with Account No. 124535-001 placed in my bag was inadvertently misplaced by me and despite utmost
efforts to recover my said Savings Account Passbook, I failed to find or locate the
same;
3. That the said Savings Passbook Account was lost and my earnest efforts to
recover it proved futile;
4. That in case of issuance of new copy of my said Passbook, I hold the Card

Bank, Inc. free of any liability to any third person who may be prejudiced thereby;
5. That this Affidavit is being executed to attest to the above-stated facts and as
supporting document for my request to the ___________________ to issue to me a
new copy of my said Savings Passbook in lieu of the one that was lost and for any legal
purpose it may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 15 th day of April
2011 at the Dolores, Quezon, Philippines.

OWEN B. FERNANDEZ
(Affiant)
CEI: Postal ID No. 10155101
SUBSCRIBED AND SWORN TO before me this 15th day of April, 2011 at the
Dolores, Quezon, Philippines.

SUGAR SHANE M. MUSLIM

Notary Public
Until December 31, 2011
In the Municipality of Tukmulan, Bangway
PTR No. 144098/01-11-11/
IBP No. 543312/01-11-11/d
Roll No. 34440
Compliance No. IV-00032244/3-1-2009;
Doc. No. 002 Page No. 03;
Book No. II; Series of 2011